Grievance and Appeals Manager, South San Francisco, CA
GRIEVANCE AND APPEALS MANAGER
The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Grievance and Appeals Manager to work in collaboration with other departments, oversee member complaints for all lines of business in a manner consistent with regulatory requirements and plan policies and procedures. The essential duties & responsibilities will include the following:
- Accomplish staff results by communicating job expectations; planning, monitoring, and appraising job results; coaching, counseling, and implementing corrective action steps when necessary; developing, coordinating, and enforcing systems, policies, procedures, and productivity standards. Complete performance evaluations in a timely manner.
- Establish and monitor processes to oversee and coordinate the identification, documentation, reporting, investigation and timely resolution of member complaints; and maintain oversight of regulatory complaint and appeal investigations.
- Ensure compliance with state and federal regulations as they relate to grievance and appeals issues; and review, audit and submit reports on grievance and appeals activities to regulatory agencies.
- Coordinate the HPSM component of the State Hearing, Independent Medical Review (IMR), and/or DMHC appeal processes. In addition, serve as the key contact or designate an appropriate contact to represent HPSM at State Hearings, including the preparation for such hearings.
- Review updates to regulations impacting grievance and appeals; conduct an annual review of Grievance and Appeals policies and procedures and work instructions to ensure consistency with regulatory changes and make revisions as appropriate.
- Provide technical content expertise to the composition of grievance resolution letters to ensure regulatory and contractual compliance, as well as assure that the issues raised in the complaint are fully addressed.
- Serve as primary liaison with other departments to resolve complex grievance issues.
- Provide oversight and management of interdepartmental committees and/or work groups, including the internal Staff Grievance and Appeals Committee, and prepare summary data and analysis to report to HPSM oversight committees such as the Service Quality Improvement Committee and the Consumer Advisory Committee.
- Maintain accurate and complete appeals/grievance records in the database.
- Participate in audits and prepare responses to audit findings and/or corrective action as needed.
- Conduct regular audits of Grievance and Appeals Coordinators’ work, analyze results, coordinate the collection of deliverables, and execute corrective action plans (CAP) to address any identified issues.
- Review, analyze, report on grievance and appeal program performance and trends and recommend opportunities for process improvement and/or corrective action as necessary. Prepare provider-specific complaint reports for Provider Services.
- Collaborate with HPSM departments to develop and implement solutions.
- Analyze new or updated regulations, laws and contract language and implement appropriate changes to internal policies, procedures and workflows.
Education and Experience: Bachelor’s degree and/or Master’s degree in related health care field preferred (Public Health, Heath Care Administration, Business, Social Services, Humanities and Policy). Minimum of three (3) years of health care management experience, preferably in managed care environment in related area of responsibility. Master’s degree can be substituted for two (2) years of relevant work experience.
Knowledge of: Principles and methods of planning, directing and maintaining compliance with regulatory standards. HMO, Medi-Cal/Medicaid, Medicare and insurance programs relating to grievance and appeals process including state and federal standards and regulations for member and provider rights and responsibilities. Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, and PowerPoint. Managerial/Supervisory principles and practices as well as techniques and methods
Ability to: Communicate effectively, both in writing and orally, as well as possess a high level of attention to detail. Make presentations to internal and external audiences and represent the HPSM in a positive manner. Communicate and present complex data and concepts in a manner that is easily understandable to a wide range of audiences. Interpret state and federal regulations, laws, and contractual obligations and translate them into policies, procedures, standards and guidelines. Plan, assign, supervise and evaluate the work of others and monitor goals, objectives, deadlines and priorities. Summarize, draw conclusions from, and communicate data and trends for planning and compliance purposes.
Starting Compensation Range: Between $74,500-$96,676 – depending on experience.
Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s coverage in the medical HMO plan and majority of PPO medical cost. Employee pays a small portion of the dependent premiums for medical and dental benefits. Additional HPSM benefits include fully paid vision, life, AD&D, STD, and LTD insurance; 457 Plan in lieu of social security (7.5% of salary/HPSM paid); retirement plan (10% of salary for compensation/HPSM paid); holiday and vacation pay; tuition reimbursement plan; and more.
Application Process: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 801 Gateway Blvd., Suite 100, South San Francisco, CA 94080 or via email: firstname.lastname@example.org or via fax: (650) 616-8039. File by: Continuous until filled. EOE